journal of pain research, 9: 661-669
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Hsiung, N-H., Yang, Y., Lee, M S., Dalal, K., Smith, G D. (2016)Translation, adaptation, and validation of the behavioral pain scale and the critical-care painobservational tools in Taiwan.Journal of Pain Research, 9: 661-669https://doi.org/10.2147/JPR.S91036
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Translation, adaptation, and validation of the behavioral pain scale and the critical-care pain observational tools in Taiwan
nai-huan hsiung1
Yen Yang1
Ming shinn lee2
Koustuv Dalal3
graeme D smith4
1Department of nursing, college of nursing, Tzu chi University of science and Technology, 2Department of curriculum Design and human Potentials Development, national Dong hwa University, hualien, Taiwan, Republic of china; 3Department of Public health science, school of health sciences, Örebro University, Örebro, sweden; 4school of nursing, Midwifery & social care, edinburgh napier University, edinburgh, UK
correspondence: nai-huan hsiung Department of nursing, college of nursing, Tzu chi University of science and Technology, no 880, section 2, chien-Kou Road, hualien 970, Taiwan, Republic of china Tel +886 3 857 2158 ext 2798 Fax +886 3 857 7962 email [email protected] Koustuv Dalal Department of Public health science, school of health sciences, Prisma house, Örebro University, Örebro 701 82, sweden Tel +46 19 30 1011 email [email protected]
Abstract: This study describes the cultural adaptation and testing of the behavioral pain scale (BPS)
and the critical-care pain observation tools (CPOT) for pain assessment in Taiwan. The cross-cultural
adaptation followed the steps of translation, including forward translation, back-translation, evaluation
of the translations by a committee of experts, adjustments, and then piloting of the prefinal versions
of the BPS and the CPOT. A content validity index was used to assess content validities of the BPS
and the CPOT, with 0.80 preset as the level that would be regarded as acceptable. The principal
investigator then made adjustments when the content validity index was ,0.80. The pilot test was
performed with a sample of ten purposively selected patients by 2 medical staff from a medical care
center in Taiwan. The BPS and the CPOT are adequate instruments for the assessment of pain levels
in patients who cannot communicate due to sedation and ventilation treatments.
Keywords: pain, scales, BPS, CPOT, Taiwan
IntroductionThe World Health Organization has estimated that 83% of the world’s population lives
with moderate-to-severe pain, amounting to tens of millions of patients who are suf-
fering without adequate treatment.1 Accurate assessment of pain among the critically
ill patients is undoubtedly a challenge for providing appropriate care.
Pain is subjectiveA person’s self-report is the most reliable measure of pain. Unfortunately, health care
professionals tend to underestimate its severity.2,3 Critically ill patients usually cannot
verbally express their pain when sedated or while undergoing ventilated treatments.
Even if multidimensional tools are reliable and valid, they may not be practical for
special populations, such as 1) children, 2) people unable to communicate, 3) people
with dementia, 4) people suffering from poststroke syndrome, and 5) people with
mental illness.2 The verbal rating scale, visual analog scale, and numeric rating scale
are reliable and valid self-rating instruments for many patient populations, although
not specifically tested in intensive care units (ICUs).4 Facial pain rating scale, visual
analog scale, and McGill Pain Questionnaire are frequently used scales in the clinical
setting.5,6 However, this cannot resolve the problem as they rely on the patient’s ability
to communicate with the care provider. Behavioral–physiological parametric scales
may be more useful in assessing pain in these patients.7
Studies7,8 have indicated that the behavioral pain scale (BPS) and the critical-care
pain observational tools (CPOT) show good reliability and validity across multiple
Journal of Pain Research 2016:9
Table 1 summary of differences between versions 1 and 2 prepared during translation of the BPs
Indicators English original of item’s description
Translated version (traditional Chinese) Adjustments to traditional Chinese
Reasons
Translator 1 Translator 2
Facial expression Partially tightened (eg, brow lowering)
部分緊繃 (例如:眉毛下彎) 部分緊繃 (例如:皺眉) 部分緊繃 (例如 ) conceptual
grimacing 痛苦表情 做鬼臉/面部猙獰 做鬼臉/面部猙獰 semanticUpper limb no movement 靜止不動 無活動 無活動 semanticcompliance with ventilation
Tolerating movement
可忍受且能 可忍受且能順應移動 可忍受且能順應移動 normative
Note: Different wordings are shown by bold chinese characters.Abbreviation: BPs, behavioral pain scale.
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hsiung et al
patient populations. These two tools allow a numerical score
at each assessment, which is easy for documentation and
comparable over time.7
Behavioral pain scaleThe BPS was developed by Payen et al9 to assess pain among
unconscious, mechanically ventilated patients. The BPS is
based on the total score of three behavioral expressions:
1) facial expression, 2) upper limb movements, and 3) com-
pliance with mechanical ventilation. The BPS allows the
assessor to derive a score between 3 (no pain) and 12 (highest
pain score), as presented in Table 1. According to previous
studies, the BPS has moderate internal consistency (with
Cronbach’s α ranging from 0.64 to 0.79) and interrater reli-
ability (with moderate agreement percentages: 50%–100%)
or high interrater coefficients (κ=0.67–0.89; interclass cor-
relation [ICC] =0.58–0.95).4,9 Discriminant validation was
supported with higher BPS scores during various painful
procedures (suction and positioning) compared with nonpain-
ful procedures (P,0.01).2,9–12,14 The BPS also has a moderate
positive correlation with self-reported pain using numerical
rating scale (NRS) tested among 13 patients.10
critical-care pain observational toolThe CPOT, developed by Gélinas et al,15 is written in French
and has been developed in Canada. Due to its usefulness,
increased interest in using CPOT is also growing in other
countries.12,13,16–20 CPOT has four sections, each with dif-
ferent behavioral categories: 1) facial expression, 2) body
movements, 3) muscle tension, and 4) compliance with the
ventilator for intubated patients or vocalization for extubated
patients with critical illness (Table 2). It includes four behav-
iors rated on a 0–2 scale, for a possible total score ranging
from 0 to 8. Each behavior is rated based on the intensity of
the reaction observed, as described by Gélinas et al.15
Gélinas et al15,21 have reported that the CPOT has good
internal consistency (standardized Cronbach’s α=0.89),
moderate-to-high interrater reliability (κ=0.52–1; ICC =0.80–
0.93), and agreement percentages (.80%). Discriminant
validation was supported with higher CPOT scores during
a painful procedure (eg, positioning) compared with rest
or a nonpainful procedure (eg, noninvasive blood pressure
recording) (P#0.001). Criterion validation was also shown,
with moderate correlations between the CPOT score and
the patient’s self-report of pain intensity at rest (P#0.001).
In many countries, CPOT had yielded good consistency and
validation.12,13,16–20 However, the Swedish version showed a
low-weighted kappa coefficient (κ=0.26).18
A systematic review indicated that BPS and CPOT were
not well developed in the Chinese language, and they have not
been widely tested for robustness in Chinese populations.22
To apply the BPS and the CPOT among the Chinese popu-
lation, an accurate Chinese version must first be developed
and tested as the world has a major percentage of Chinese-
speaking population. Translation is the most common method
of preparing instruments for cross-cultural research, but
problems exist that may potentially threaten validity, and
these must be overcome.23 The specific validation method
adopted is less important than the recognition that the transla-
tion process must be appropriate and the validation process
rigorous.23 Although team translation procedures have been
recommended by Harkness,24 there are no established gold
standards of good instrument translation and interpretation.
Hence, this current study used the questionnaire translation
procedure recommended by Harkness24 and the seminal trans-
lating work of Brislin25 on computer translating programs for
constructing these scales.
ObjectiveThe objective was to evaluate a translation of the BPS and the
CPOT in the traditional Chinese language spoken in Taiwan.
Translation accuracy, content validity, and ascertainment of
clear understanding of the scale by health caregivers to assess
non-verbal communication patients were investigated.
Journal of Pain Research 2016:9
Table 2 summary of differences between versions 1 and 2 created during translation of the cPOT
Indicators Original version of item’s description (English)
Translated version (traditional Chinese) Adjustments to traditional Chinese
Reasons
Translator 1 Translator 2
Facial expression
no muscular tension observed (relaxed and neutral)
無察覺肌肉 (放鬆, 自然)
無 肌肉緊繃 (自然放鬆) (放鬆, 自然)
無明顯肌肉緊繃 (自然放鬆) (放鬆, 自然)
semantic
Presence of frowning, brow lowering, orbit tightening, and levator contraction
出現皺眉, 眉毛下彎, 眼眶緊繃, 眼瞼肌收縮之表情
前額皺紋, 皺眉, 雙目緊睜, 快速眨眼
出現皺眉, 眉毛下彎, 雙目緊睜, 眼瞼肌收縮之表情
semantic
all of the above facial movements plus eyelid tightly closed (grimacing)
含上述表情及
眼瞼緊閉
(痛苦表情)
含上述臉部表情
及雙目緊閉 (面部扭曲)
含上述臉部表情及雙目緊閉 (面部扭曲)
semantic
Body movements
Does not move at all 靜止不動 完全不活動 靜止不動 conceptualPulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed (restlessness)
拉管, 嘗試坐起, 移動四肢/敲打, 無法接受指令, 攻擊照護人員, 嘗試爬下床 (身體隨時都在移動)
拔管, 嘗試坐起, 移動四肢/揮舞, 攻擊醫護人員, 設法離開病床 (坐立不安)
拔管, 嘗試坐起, 移動四肢/揮舞, 攻擊醫護人員, 嘗試爬下床
(坐立不安)
semantic conceptual
compliance with the ventilator (intubated patients)
asynchrony: blocking ventilation, alarms frequently activated
呼吸阻斷, 警報時常響起
:警報常常響起, 呼吸不時受阻
:呼吸阻斷, 警報常常響起
normative
Vocalization (extubated patients)
Talking in normal tone or no sound 話聲調正常或是
沒聲音
話正常, 無異常聲 話聲調正常或是沒聲音 semantic
Note: Different wordings are shown by bold chinese characters.Abbreviation: cPOT, critical-care pain observational tools.
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Pain scales
MethodsThe measuring instruments used in this study were repro-
duced from existing tools, and permissions were sought from
the original authors. To reproduce a copyrighted work for
the use of developing scales in nonprofit academic research,
permission is not necessary.26 According to Harkness24
and Streiner and Norman,27 adapting measures for cross-
cultural research involve a four-stage process of translation:
1) forward translation, 2) back-translation, 3) expert reviews,
and 4) adjustments and a pilot study (Figure 1).
Forward translationPermission to use the Chinese language version of the BPS
and the CPOT was approved individually by the respective
authorities. The BPS and the CPOT were independently
translated from the original language English into tradi-
tional Chinese. This was accomplished by employing two
native Taiwanese bilinguals in both English and Mandarin.
The initial translations by both translators were carried out
independently without any communication. One translator
holds a Master’s degree in linguistic studies, and the other
has a PhD degree in biochemistry. Another linguistic expert
participated during the verification process. The primary
researcher ensured greater ease of comprehensibility of
the translated tool to nurses. Each translation was further
refined and a summary of the adjustments was compiled.
The final translated questionnaire was sent to the general
coordinator of the project, who did not indicate any further
adjustments.
Back-translationThe independent back-translation of the BPS and the CPOT
to English was conducted by two other Chinese bilingual
translators. The translators’ native language was English as
spoken in USA. The first translator was a medical doctor in
Taiwan. The second translator was bilingual in traditional
Chinese and English and had completed her Bachelor’s and
Master of Nursing degree in USA. At no time had either of
the translators accessed the English CPOT and BPS scales
for comparison. Moreover, they did not use any experience/
concept generated in their professional lives. The scales were
then resubmitted to the general coordinator of the project,
who amended them to allow for accurate use across the
English-speaking world (ie, UK, Australia, and USA). The
back-translated versions of the BPS and the CPOT were
evaluated by the primary researcher and compared to the
original in English to identify any discrepancies or incon-
sistencies in the traditional Chinese version.
Journal of Pain Research 2016:9
Forward translation 1:
Backward translation 2:
Expert reviews to assess content validity:
Backward translation 2:
Forward translation 2:• Translated tools into traditional Chinese by Chinese translator with Master’s degree in English
• Back-translation of tools into English by Chinese clinical physician with first language as English
• 2 Clinical nurses with Master’s degrees from the USA or Australia• 1 Nursing professor with PhD from the USA• 1 Physician of anesthesia medicine specialized in pain treatment and surgical intensive care
• 1 Associated professor in anesthesiology with PhD in clinical medicine• 1 Anesthetist
• 1 Physician of cardiac medicine• 1 Physician of neurological medicine
• Conducting a preliminary test to analyze reliabilities of the BPS and the CPOT• Procedures to identify and eliminate problems, allowing programs to be made
The best traditional Chinese version of the BPS and the CPOT
Adjustment:
Approval by the pilot study:
The final versions of the BPS and theCPOT
• Back-translation of tools into English by Chinese clinical physician with first language as English
• Translated tools into traditional Chinese by Chinese translator with Master’s degree in English
Clarificationby the primary researcher
Figure 1 Process of translating the pain scales.Abbreviations: BPs, behavioral pain scale; cPOT, critical-care pain observational tools.
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hsiung et al
After the translation, the initial content validity of each
item was reviewed by two bilingual (English–Mandarin
speaking) epidemiologists. They collaborated with the Pain
Research Group for semantic equivalence, clarity, and gram-
matical accuracy. Minor modifications suggested by two
clinical nurses were incorporated to preserve semantic and
idiomatic equivalence in traditional Chinese characters for
Mandarin-speaking nurses. Words and phrases that might
diverge in meaning, detected during comparison of the trans-
lated version with the original, and for which doubt existed
were discussed with the translator.
expert group for critical reviewAn expert group was established for critically monitoring
and reviewing the whole process, which consisted of senior
researchers from Taiwan and Europe drawn from different
relevant fields: two clinical nurses, a nursing professor,
a public health professor, a medical physician, a surgical
physician of neurological medicine, an anesthetist, an asso-
ciate professor in anesthesiology, a physician of anesthesia
medicine specialized in pain treatment and surgical intensive
care, and a professor of curriculum development. Agreement
was achieved for all items concerning the relevance, as well
as for the definitions of all items in the BPS and the CPOT.
One item (facial expression) in both the BPS and the CPOT
achieved total consensus concerning its relevance (Table 3).
The content validity index (CVI) was .0.80 for all items of
the BPS and the CPOT, showing satisfactory agreement. The
prefinal version of the BPS and the CPOT that was obtained
at this stage was then tested in the pilot study.
Journal of Pain Research 2016:9
Table 3 expert agreement (n=8) on the items in the chinese versions of BPs and cPOT concerning content validity (relevance and definition) and acceptability of the scale
Items Pain score
Scorea
Relevance Definition Acceptability
4 3 2 1 4 3 2 1 4 3 2 1
BPSFacial expression 8 0 0 0 8 0 0 0 8 0 0 0 Relaxed 1 8 0 0 0 8 0 0 0 8 0 0 0 Partially tightened (eg, brow lowering) 2 8 0 0 0 8 0 0 0 8 0 0 0 Fully tightened (eg, eyelid closing) 3 8 0 0 0 8 0 0 0 8 0 0 0 grimacing 4 8 0 0 0 8 0 0 0 8 0 0 0Upper limbs 8 0 0 0 3 4 1 0 7 1 0 0 no movement 1 8 0 0 0 8 0 0 0 8 0 0 0 Partially bent 2 8 0 0 0 3 4 1 0 7 1 0 0 Fully bent with finger flexion 3 8 0 0 0 8 0 0 0 8 0 0 0 Permanently retracted 4 8 0 0 0 8 0 0 0 8 0 0 0compliance with the ventilator 6 2 0 0 8 0 0 0 7 1 0 0 Tolerating movement 1 8 0 0 0 8 0 0 0 8 0 0 0 coughing with movement 2 6 2 0 0 8 0 0 0 7 1 0 0 Fighting ventilator 3 6 2 0 0 8 0 0 0 8 0 0 0 Unable to control ventilation 4 8 0 0 0 8 0 0 0 8 0 0 0CPOTFacial expression 8 0 0 0 8 0 0 0 8 0 0 0 no muscular tension observed 0 8 0 0 0 8 0 0 0 8 0 0 0 Presence of frowning, brow lowering,
orbit tightening, and levator contraction1 8 0 0 0 8 0 0 0 8 0 0 0
all of the above facial movements plus eyelid tightly closed
2 8 0 0 0 8 0 0 0 8 0 0 0
Body movement 5 3 0 0 8 0 0 0 6 2 0 0 Does not move at all (does not
necessarily mean absence of pain)0 8 0 0 0 8 0 0 0 8 0 0 0
slow, cautious movements, touching or rubbing the pain site, and seeking attention through movements
1 5 3 0 0 8 0 0 0 6 2 0 0
Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, and trying to climb out of bed
2 8 0 0 0 8 0 0 0 8 0 0 0
Muscle tension 3 4 1 0 8 0 0 0 2 5 1 0 no resistance to passive movements 0 Resistance to passive movements 1 4 3 1 0 8 0 0 0 2 5 1 0 strong resistance to passive movements,
inability to complete them2
compliance with the ventilator (intubated) 7 1 0 0 8 0 0 0 7 1 0 0 alarms not activated, easy ventilation 0 8 0 0 0 8 0 0 0 8 0 0 0 alarms stop spontaneously 1 7 1 0 0 8 0 0 0 7 1 0 0 asynchrony: blocking ventilation, alarms
frequently activated2 8 0 0 0 8 0 0 0 8 0 0 0
Notes: a1, not relevant; 2, somewhat relevant; 3, quite relevant; 4, highly relevant. The level of agreement was set to no more than one panel member scoring an item at ,3.Abbreviations: BPs, behavioral pain scale; cPOT, critical-care pain observational tools.
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Pain scales
The translated and back-translated versions of the question-
naire were submitted to the expert committee of specialists in the
subject area. This study then invited reviewers who are experts in
different areas of practice to assess the drafts of the two survey
instruments for content validity. They evaluated the translations.
The amendments and the results produced a prefinal version of
the BPS and the CPOT. As part of this process, the relevance of
the content validity within the questions was confirmed. A CVI
was derived for each item of the BPS and the CPOT. To compute
the CVI, a four-point scale of item relevance (1, not relevant; 2,
somewhat relevant; 3, quite relevant; 4, highly relevant) was used
to determine the relevance of the item as per expert opinion.28
The CVI is computed at 0.80, which indicates the percentage
of agreement between the experts.29
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hsiung et al
adjustmentsAccording to the specialists’ guidance, where the CVI was
,0.80, further adjustments were required.30 The prefinal
versions of the BPS and CPOT were then tested in a pilot
study for reliability and repeatability.
Pilot testingTo design a productive study requires a pilot study.31
Conducting a pilot study does not guarantee success in the full
study, but it may improve the likelihood and provide valuable
insights for the main study.32 Pilot studies for comparative
randomized trials are routinely designed to provide prelimi-
nary evidence and determine the feasibility or the clinical
efficacy of an intervention.33 The objective of the pilot study
was to establish whether the pain scales could be satisfac-
torily understood and completed by medical staff with the
target patient population of unconscious and/or sedated and
ventilated conditions in the ICU.
setting and subjectsThe study was performed at the surgical ICU at a medical
center in Hualien, Taiwan. In total, observations of ten patients
over two assessment occasions were conducted for a total of
40 BPS and CPOT assessments. Inclusion criteria for patients
were as follows: 1) residence in the ICU for $24 hours,
2) age $18 years, 3) presence of a defined pain focus, ie,
endotracheal tube, and 4) inability to communicate verbally.
Exclusion criteria were as follows: 1) continuous noninvasive
ventilation, 2) cerebral injury, 3) facial injury, 4) arm injuries,
5) treatment with muscular blocking agents, and 6) presence
of muscular dysfunction due to stroke or tetraplegia.
Data collectionPatients were observed at two points in time: at rest and dur-
ing the painful procedure. The painful procedure consisted of
endotracheal suctioning (ETS) of the patient, which has been
reported as a painful stimulus.34–36 Two ICU nurses assessed
patients independently but simultaneously to score the pain
behaviors of 40 observations based on the BPS and the CPOT.
The ICU nurses were trained to use the BPS and the CPOT
in a 2-hour training session.
ethical permissionApproval for this study was obtained from the Institutional
Review Board of Tzu Chi Hospital (IRB100-23). As this
study did not deviate from routine nursing care, informed
patient consent was not required. The study was communi-
cated to the involved ICUs through staff meetings.
analysisThe data collected were entered into an electronic spread
sheet (Excel®, Version 2010) and analyzed using simple
descriptive statistics, by Statistical Package for the Social
Sciences 19.0, including mean values and standard devia-
tions. The main focus was on questionnaire items that had
not been satisfactorily answered. Reliability analyses were
performed by calculating the ICCs between the BPS or
CPOT scores for independent raters. Cronbach’s α was also
examined for internal consistency of BPS and CPOT. To test
validities, this study provides evidence of content validity by
computing a CVI. The ratings of individual items are based
on the relevance as assigned by eight experts.
ResultsAs previously described, the adaptation of the BPS and the
CPOT involved a series of stages, comprising 1) translation,
2) back-translation, 3) evaluation by an experts committee
review, and 4) pilot testing of the prefinal version.
TranslationDuring the translation, it was necessary to adapt several terms
between the two translations (versions 1 and 2) to maintain the
original meaning. Tables 1 and 2 present the original English
version and the discrepancies between the two translations into
the traditional Chinese versions 1 and 2 of BPS and CPOT. Some
of the items encountered required alteration in the Chinese ver-
sion due to semantic, conceptual, and normative equivalences.
Back-translationDuring back-translation of the BPS and the CPOT, no items
required alteration. The scales retained the meaning of the
original version. Both scales were checked for words and
phrases that might imply a divergence of meaning when
comparing the back-translated version to the original.
Patients’ profilesTen participants were selected by using purposive sampling
in this pilot study (five males and five females). Participant’s
characteristics are described in Table 4. Median age was
66 years (ranging from 40 years to 84 years) with variable
diagnoses. Sedative and analgesic agents were administered
according to physician’s orders and were not standardized for
the purpose of this pilot study.
scale validationThis pilot study collected patients’ pain scores during rest
and the suction procedure. Results showed that between rest
Journal of Pain Research 2016:9
Table 4 Description of characteristics of patients in the pilot study
ID Sex Age, years Diagnosis APACHE II Sedation (daily dose)a
Analgesia (daily dose)b
1 M 49 hepatocellular carcinoma 25 lorazepam (7.9 ml) Fentanyl (0.81 ml)2 F 77 Pneumonia 26 lorazepam (7.1 ml) Fentanyl (0.76 ml)3 M 58 acute pancreatitis 29 lorazepam (35.0 ml) Fentanyl (3.47 ml)4 M 84 Pneumonia 28 none Fentanyl (0.70 ml)5 M 48 septic shock 24 none Fentanyl (0.20 ml)6 M 48 gastrointestinal bleeding 19 none Fentanyl (2.46 ml)7 F 69 Respiratory failure 31 lorazepam (19.0 ml) Fentanyl (2.02 ml)8 F 40 Respiratory failure 32 lorazepam (19.7 ml) Fentanyl (1.98 ml)9 F 41 Pneumonia 26 lorazepam (22.5 ml) Fentanyl (2.18 ml)10 F 69 acute pyelonephritis 23 lorazepam (23.4 ml) Fentanyl (1.19 ml)
Notes: aintravenous infusion. bintermittent intravenous doses. aPache score: an integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death.Abbreviations: aPache ii, acute Physiology and chronic health evaluation; F, female; M, male.
Table 5 Distribution of BPs and cPOT scores during each assessment in the pilot study (n=10)
ID BPS (scores 3–12) CPOT (scores 0–8)
Rest ETS Rest ETS
1 3 6 0 32 4 5 1 33 4 5 1 24 4 6 1 25 4 4 1 16 4 4 0 27 4 5 2 38 3 4 1 29 3 5 0 210 4 6 1 4Median 4 5 1 2
Abbreviations: BPs, behavioral pain scale; cPOT, critical-care pain observational tools; eTs, endotracheal suctioning.
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and the ETS, a total of 100% of patients showed an increased
score for the BPS compared to 90% of the patients for the
CPOT (Table 5). The median scores increased from 4 to
5 in the BPS and 1 to 2 in the CPOT, during rest and ETS
(Table 5).
The BPS scores were similar to those obtained in the
CPOT. Internal consistency of the BPS (α=0.744) and the
CPOT (α=0.697) was established based on the ten subjects’
responses. No items on either the BPS or the CPOT had a zero
response, a one response, or a negative response, which would
require their elimination. As the alpha could not be improved
by deletion of items, nor could it substantially improve reli-
ability, the scale was not further altered (Table 6).
It was necessary to adapt some terms in the Chinese ver-
sion to retain the original meanings of the BPS and the CPOT.
Some important modifications were carried out in the forward
translation of the BPS and the CPOT. This was necessary
as a result of the need to validate the cross-cultural and
language-based differences. These modifications consisted
of the following: 1) selecting the term, wording, and verb
tense for conceptual accuracy and 2) assessing consistency
of the medical care staff and their accurate use of the scales
to assess pain. This process ensured that the survey collected
high-quality generalizable data for the project and could
uncover useful information from the respondents.37
Tables 5 and 6 present the results of the pilot testing. In
general, the BPS and the CPOT were reported to be com-
prehensive and well formatted for ease of use on the care
facilities. The Cronbach’s α for reliability of the three-item
measure of the BPS was 0.744 and of the four-item mea-
sure of the CPOT, it was 0.697. In Table 6, the item with
the greatest effect on the BPS appears to be item II (upper
limbs), with r=0.542. Similarly, the most influential item of
the CPOT is item II (body movements), with an item-total
correlation of r=0.562. Although the item with the lowest
item-total correlation for the CPOT is item IV (r=0.075), it
was not deleted because compliance with ventilation remains
an important pain indicator. Item III (compliance with the
ventilator) in the BPS and item IV (compliance with the
ventilator) in the CPOT are extremely important and easily
recognizable visual pain indicators. To assess the effect of
the deletion of this item on the overall Cronbach’s α of both
scales, the reliability was recalculated. The “alpha if item
deleted” values are both greater than the overall alpha, which
suggests that these items lack relevance to the scales. The
study reran the reliability analysis with that item removed.
However, when items I and II in the BPS, or items I, II, and III
in the CPOT, were removed, the overall alphas of the BPS
and the CPOT were decreased in both cases. As this study
relies on accepted scales obtained from a published source,
Journal of Pain Research 2016:9
Table 6 Intraclass correlation coefficients of the BPS and the CPOT scores during the painful procedure in the pilot study (n=10)
Internal consistency Cronbach’s α (total items)
Scale mean if item deleted
Scale variance if item deleted
Item-total correlation
Cronbach’s α if item deleted
BPs 0.744 Facial expression 8.15 2.555 0.474 0.723 Upper limbs 9.15 2.239 0.542 0.684 compliance with the ventilator 9.70 2.958 0.457 0.755cPOT 0.697 Facial expression 4.40 2.463 0.542 0.618 Body movement 5.15 2.345 0.562 0.605 Muscle tension 4.80 3.011 0.355 0.629 compliance with the ventilator 5.60 3.305 0.075 0.749
Abbreviations: BPs, behavioral pain scale; cPOT, critical-care pain observational tools.
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hsiung et al
it is possible to meaningfully compare the results of other
researchers using the same scale. This study did not remove
any item from the two scales.
DiscussionThe traditional Chinese versions of the BPS and the CPOT
have been shown to be useful scales for the bedside assess-
ment of pain among patients who are unable to communi-
cate or are unconscious. The validity of this scale for pain
management among the Chinese population requires further
study to allow for better implementation within the hospital
system. Limitations of this study include the self-evident fact
that patients who cannot communicate their experience of
pain are at the mercy of careful observation of the medical
staff. A study of both pre- and postpain experiences within
the medical system will allow for greater understanding of
the patient experience and allow for improved pain manage-
ment.7,8,12,13 Consistent with previous studies, the BPS and the
CPOT indexes were sensitive to painful procedures in this
small sample of unconscious ICU patients.7,8,12,13 The findings
of this study suggest that the Chinese version of the BPS and
the CPOT can be recommended as an instrument for assessing
pain among critically ill adults. However, to achieve enhanced
generalizability of the CPOT, further evaluation of CPOT in
broader groups of critically ill patients is warranted.
DisclosureThe authors report no conflicts of interest in this work.
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